Provider Demographics
NPI:1174187447
Name:NINIS, ANGELA (PTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:NINIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2377
Mailing Address - Country:US
Mailing Address - Phone:321-662-1932
Mailing Address - Fax:
Practice Address - Street 1:604 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2377
Practice Address - Country:US
Practice Address - Phone:321-662-1932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004914225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant